DRG Coding Auditor - MS-DRG and APR-DRG

Elevance Health, Inc.; United States; Remote; USD 93,000 - 160,000; Full time

Job summary

Elevance Health, Inc. seeks a DRG Coding Auditor to audit inpatient records, validate DRG assignments, and deliver high-quality recoveries. The role emphasizes clinical review, coding accuracy, and collaboration with hospital coding teams.

Hybrid/remote work is available with in-person training sessions required. Ideal candidates have 5+ years in claims auditing and certifications such as RHIA/RHIT/CCS/CIC/CCDS, plus MS-DRG/APR-DRG experience.

Qualifications

• Requires AA/AS degree or 5+ years of experience in claims auditing, quality assurance, or recovery auditing.
• Certifications include RHIA, RHIT, CCS, CIC, or CCDS.
• Requires 5 years of experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Responsibilities

• Audits inpatient medical records and generates recoverable claims for all lines of business.
• Performs clinical reviews of medical records to evaluate DRG assignment accuracy.
• Draws on ICD-10 coding expertise and clinical guidelines to substantiate audit conclusions.
• Uses audit tools and workflow systems to generate audit findings letters.

Skills

ICD-10 coding

Auditing

Clinical review

Quality assurance

Education

AA/AS degree

RHIA certification

RHIT certification

CCS certification

CIC certification

CCDS certification

Job description

DRG Coding Auditor - MS-DRG and APR-DRG

Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The DRG Coding Auditor is responsible for auditing inpatient medical records and generating high quality recoverable claims for the benefit of the company, for all lines of business, and its clients. Also responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. Specializes in review of DRG coding via medical record and attending physician's statement sent in by acute care hospitals on submitted DRG.

How you will make an impact:

• Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines and objectivity in the performance of medical audit activities.
• Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.
• Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters.
• Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing). Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re-admissions, Inpatient to Outpatient, and HACs.
• Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.

Minimum Requirements:

• Requires at least one of the following: AA/AS or minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing.
• Requires at least one of the following certifications: RHIA certification as a Registered Health Information Administrator, RHIT certification as a Registered Health Information Technician, CCS as a Cert Coding Specialist, CIC as a Certified Inpatient Coder, or Certified Clinical Documentation Specialist (CCDS).
• Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Preferred Skills, Capabilities and Experiences:

• BA/BS preferred.
• Experience with vendor based DRG Coding / Clinical Validation Audit setting or hospital coding or quality assurance environment preferred.
• Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $92,880 - $160,218.

Locations: California; Illinois; Maryland; New York; Virginia

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.